At first glance, it might seem odd for an American medical society to have an international presence. What could be the motivation? Is it just a way for the American College of Cardiology (ACC) to increase its membership? Or is it an expansionistic impulse to influence indigenous care systems with American models? In a word: no. Cardiovascular disease (CVD) is a global problem, complex in its manifestations and mediated by cultural influences, such as diet and lifestyle factors. Comparisons across the globe of issues and approaches to CVD can provide crucial insights, unattainable within any one homogeneous group. In this President's Page we want to describe the ACC's efforts in the international arena.

An American Organization Founded by…a German?

German cardiologist Franz Groedel, MD, was a pioneer in electrocardiography and cardiac radiology (1). He exerted considerable influence on European medicine—in fact, he co-founded the German Society for Heart and Circulatory Research in 1928—but the Nazi rise to power altered his course. With a Jewish mother, Groedel was considered non-Aryan and his career was at risk. Wisely choosing to emigrate sooner rather than later, he arrived in New York City in 1933 at the age of 52. Unfortunately, beleaguered American physicians suffering the contractions of the Great Depression were less than welcoming of competition from immigrant practitioners, and Groedel found himself barred from New York's elite medical circles. He nonetheless managed to develop a practice on Park Avenue and soon gravitated to leadership positions in medical societies that catered to foreign physicians. He became President of the Rudolf Virchow Medical Society of New York in 1943, President of the New York Cardiological Society in 1949, and chartered the ACC in late 1949.

Groedel was unable to witness the fruits of this final labor: he was too ill to attend the first scientific sessions, held in 1951, and died 1 week later. The cosmopolitan spirit was already embedded in the organization, however, and within 2 years, the ACC had its first international member practicing outside the United States. During the 1960s, pioneered by past ACC President Eliot Corday, MD, the ACC started International Circuit Courses, and before long, was conducting more than 40 around the world. The College continues this outreach today, with its leadership attending more than 50 overseas meetings each year.

International Relations, Then and Now

Given this history, why did the ACC feel it necessary to refocus its international endeavors and establish a new international strategy beginning in 2006? For those of you who read the President's Page last month, it was a simple matter of “Plan, Do, Study, Act” (PDSA) (2).

In 2005, the College asked its international members for feedback, and the response was sobering. Growing economic inequality was part of the problem. International members had begun to feel that their membership dues, in the context of some economies, had become prohibitively high, incorporating advocacy efforts that may not be directly relevant internationally. The College responded by reducing the dues significantly and introducing tiered levels of membership dues to reflect differences in countries' economic development.

The struggles within the U.S. to grapple with the pressures of American healthcare policy were another part of the problem. The ACC, understandably, had tried to keep its membership abreast of issues pressing to American practitioners, but had neglected global perspectives—and even the instructive lessons that other systems could offer. This was exacerbated by the fact that the ACC's international activities were governed by a committee made up predominantly of U.S. fellows. So the ACC created an International Council that would be composed primarily of members working outside the United States and could inform the Board not only of the needs of our international members but of opportunities to collaborate in the Americas and overseas.

In 2008, the International Council, with the enthusiastic endorsement of the ACC's Board of Trustees, inaugurated a new era in the College's international outreach with the formation of International Chapters, of which the framework of governance and representation parallels that of U.S. chapters. To avoid being regarded as a competitor to national societies, the ACC stipulated from the outset that the relevant national society must grant its approval before an ACC chapter could be formed. This modicum of courtesy has led to overseas chapters being welcomed by national societies; at the recent World Congress of Cardiology meeting in Dubai, the ACC reached a new total of 20 international chapters with the addition of Thailand and the United Arab Emirates. More chapters are in various stages of formation.

There are several motivations for members in other countries to form international chapters:

• joint sessions and a booth at each ACC annual meeting;

• complementary fellow-in-training membership for all cardiovascular trainees in that country;

• an option for a bulk international associate membership in the ACC that allows all members of a given cardiology society to access CardioSource and the Journal of the American College of Cardiology among other educational benefits.

These tangible benefits have helped attract a significant international membership, which now accounts for more than 5,600 members, or 13% of the ACC's membership. Growth in international membership has ranged from 10% to 17% per annum in recent years (faster than in any other member segment), and we now have representation in 125 countries (Fig. 1). The funds generated from various international meetings and activities more than pay for themselves, thereby ensuring that our stateside endeavors do not suffer.

With the robust development of more overseas chapters, the International Council has now metamorphosed into an Assembly of International Governors (AIG), a new body made up of all the governors of all the international chapters, along with selected leaders for regions of the world that do not have chapters. This Assembly met for the first time at ACC.12 in Chicago, Illinois, and will be able to build on the solid foundation laid down by the International Council and the committee that preceded it.

Collaborating to Conquer Preventable Disease

We have much to learn about the treatment of CVD. Disease type, occurrence, and treatment vary with many factors. Yet, as a disease category, CVD is unquestionably a leading cause of morbidity and mortality around the world. The ACC's goals with respect to international efforts are as follows:

• increase international participation in educational activities;

• increase international knowledge exchange;

• increase international participation in practice standards and quality initiatives; and

• increase communication on international activities.

These goals are driven by the seriousness of the challenges we face: in 2008, 36 million of 57 million global deaths were due to CVD (3). Last year, in collaboration with the World Heart Federation, the American Heart Association, and the European Society of Cardiology, the ACC launched an advocacy effort during the first United Nations (UN) Summit on non-communicable diseases (NCDs). The result was the publication of a UN Political Declaration that frames the global effort to combat NCDs, and just last May, the World Health Organization approved the goal of reducing mortality from NCDs by 25% by 2025. This will be challenging, yet 80% of premature heart disease, stroke, and diabetes can be prevented by addressing modifiable risk factors: tobacco, poor diet, insufficient physical activity, obesity, hypertension, and high blood sugar. The ACC and our partner organizations are working to ensure that NCDs are included in the next version of the Millennium Development Goals.

The ACC is also pursuing collaborations at a more local level, chapter by chapter. The California chapter has teamed up under a “twinning program” with the British Cardiovascular Society in education and training of cardiology fellows, as has Pennsylvania and Italy, and most recently Florida and the Spanish Cardiology Society. The College's Cardiovascular Leadership Institute program has been tailored for international audiences. After each year's Scientific Sessions, a condensed “Best of ACC” program has attracted large audiences when presented in countries overseas. With nearly 1 in 4 cardiologists in the United States being foreign medical graduates, it is natural for us to reach across national borders to improve cardiovascular care through formal training, observerships, and participating in exchange programs.

Moreover, in the area of healthcare delivery, the Science and Quality Division of the ACC has taken the lead in building a network of global registries to better study the outcomes of cardiovascular care and evaluate overall quality. Hospitals from the United Arab Emirates, Saudi Arabia, Brazil, and India are now registry partners, and the ACC hopes to launch its outpatient registry PINNACLE in China later this year.

With all our progress in health care and quality improvements, we believe we have as much to learn as to teach. Challenges and advances in both care and prevention will require that we work together, across national barriers. In this age of globalization and ever faster communication, we can share progress more quickly and collaborate more easily in education, training, scientific advances, and patient care. As the world seems to shrink, there has never been a time of greater opportunity to forge stronger personal and professional relationships, and break down international barriers. We look forward to joining forces with our international partners and celebrating our shared progress.

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